Review Article

Surprising Complication of Intussusception after Colonoscopy: A Case Report and A Review of the Literature

by Irene Ligato, Andrea Ruffa, Caterina Sbarigia, Niccolò Petrucciani, Gianluca Esposito*

Department of Medical-Surgical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Italy

*Corresponding author: Gianluca Esposito, Department of Medical-Surgical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Italy

Received Date: 11 January, 2024

Accepted Date: 16 January, 2024

Published Date: 18 January, 2024

Citation: Ligato I, Ruffa A, Sbarigia C, Petrucciani N, Esposito G (2024) Surprising Complication of Intussusception after Colonoscopy: A Case Report and A Review of the Literature. J Surg 9: 1981 https://doi.org/10.29011/2575-9760.001981

Abstract

This study discusses a case with a history of ileal-caecal intussusception post colonoscopy requiring urgent surgical intervention and a systematic review explores the literature on post-colonoscopy intussusception. A systematic review was conducted according to PRISMA guidelines. Studies reporting entero-enteric, ileo-colic, or colo-colic intussusception after colonoscopy, published in English before June 2023, were included. Data was extracted on patient demographics, indications for colonoscopy, procedural details, clinical symptoms, and management. Overall, 19 cases were identified from 17 studies. The median age was 48 years and 53 % were male. History of abdominal surgery was reported in 42% of cases. Symptoms typically appeared within a week of the procedure. The majority of cases required surgical intervention (63%), while others were managed conservatively (34%). The case report is an 85-year-old man with a history of diabetes, cardiopathy and abdominal surgery presented to the Emergency Department with 2 days of abdominal pain and vomiting after colonoscopy. A Computer Tomography abdomen revealed findings concerning for a small-bowel volvulus. Subsequent laparotomy revealed ileo-caecal intussusception, requiring surgical resection. Histology examination revealed a small-bowel intramucosal adenocarcinoma. The patient recovered and was discharged on postoperative day 7. The etiology of post-colonoscopy intussusception is multifactorial, with potential contributing factors including adhesions, altered bowel motility, and gas insufflation. Patients with a history of abdominal surgery should be considered at increased risk and prompt identification is crucial to reduce morbidity and mortality.

Keywords: Abdominal pain; Colonoscopy; Ileal tumor; Intussusception

Abbreviations:M: Male; F: Female, PPES: Post Polypectomy Electrocoagulation Syndrome

Introduction

Intussusception is defined as the invagination of one segment of the bowel (the proximal tract is the intussusceptum) into an immediately adjacent segment (the distal segment or the intussuscipiens). This action of telescoping often obstructs the passage of food or fluids. Additionally, it stops the blood supply to the affected area of the intestine, leading to possible infection, tissue necrosis, or intestinal perforation [1]. Intussusception is the most common cause of intestinal obstruction in early childhood, whilst in adults is infrequent, being approximately 5% of all intussusception cases, and typically more frequent in the small bowel rather than in the colon [2]. Among adults, intussusception commonly arises from a pathological “lead point” (which can be found intraluminal, mural or extramural), such as malignant lesions, adhesions, benign tumors, inflammatory lesions and Meckel’s diverticulum [1]. Intussusception can also occur as a complication of colonoscopy, although this condition is very rare and poorly described in the literature. Worldwide, colonoscopy is a safe procedure used for diagnosis, screening, surveillance, and treatment. The incidence of complications after colonoscopy is low and varies between diagnostic and operative colonoscopy. Globally, the incidence rate of perforation, post-colonoscopy bleeding, and mortality is reported to be 0.05%, 0.26%, and 0.0029%, respectively [3]. An important distinction within the context of colonoscopy, that is, the differentiation between diagnostic and operative colonoscopies. Diagnostic colonoscopies aim to visualize the colon and rectum to identify abnormalities, obtain biopsies, or perform other non-surgical interventions. In contrast, operative colonoscopies involve therapeutic procedures beyond mere visualization and diagnosis. These may include the removal of polyps or treatment of bleeding lesions. Operative colonoscopies are more invasive and some complications (e.g. bleeding, perforation and intussusception) are direct consequences of resections during operative endoscopic procedures like polypectomies, mucosal resections, and submucosal dissections, whilst other complications are less common and with mechanisms not completely known. Moreover, there’s no agreement concerning the temporal definition of a colonoscopy-related complication: some studies consider an event associated with the endoscopic procedure up to 7, 14 or 30 days after colonoscopy [4]. Indeed, the presence of complications up to 30 days after the colonoscopy could have a cause-and-effect relationship with the endoscopic procedure [4].

On the other hand, in patients with subacute or chronic intestinal obstruction, the colonoscopy can be an important diagnostic tool for the diagnosis of ileo-colic or colo-colic intussusception [5]. Furthermore, colonoscopy can also have a role as a potential treatment for intussusception in children. The most common clinical manifestation of intussusception is abdominal pain with associated symptoms like nausea, vomiting, gastrointestinal bleeding, constipation, or bloating. Commonly a computed tomography scan (CT) is recommended for the diagnosis. In contrast to children, abdominal surgery with bowel resection can be a valid treatment to manage intussusception-related obstruction in adults [1]. We report a case of post-colonoscopy ileo-caecal intussusception requiring urgent surgical intervention and a systematic review of current literature about intussusception post-colonoscopy.

Materials and Methods

This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [6,7]. To assess the association of intussusception after colonoscopy, two electronic databases, MEDLINE through PubMed and Embase, were searched up to June 26, 2023, using the following search query: “((((intussusception) OR (invagination)) AND (after colonoscopy)) OR (post colonoscopy)) AND (complication)”.

Study Selection

Case-report and case-series studies regarding history of entero-enteric, ileo-caecal, ileo-colic or colo-colic post colonoscopy intussusception that have been published before June 26, 2023, were retrospectively included. Studies focusing on colonoscopyrelated complication that did not refer to intussusception were excluded. Moreover, studies with unavailable or unextractable data, studies published in languages other than English, letters, comments, studies involving children, and duplicate publications were likewise excluded.

Search Strategy, Data Identification and Extraction

The research was independently conducted by three authors (IL, AR, CS). The initial screening included independent evaluations of titles. After that, the three independent reviewers assessed the abstracts of the selected titles for inclusion. A fulltext analysis and data-extraction was finally performed on the remaining studies. In case of disagreement, consensus is reached through discussion among reviewers during each of the previous phases. The reference sections from all selected studies were additionally examined to discover any further relevant paper. The following features were extracted from each study: first author, year of publication, country. For each patients, the following data were collected: age, sex, previous surgical history, indication of colonoscopy, procedural details, clinical symptoms, onset of symptoms, the intussusception type, cause of intussusception, and management.

Results

The search identified a total of 745 articles. Twenty-nine studies were excluded because they were published in languages other than English. The flow chart describing the process of study selection is shown in Figure 1. From a first screening, based on titles, 25 articles were included for abstract and full-text review. Among these studies and from the analysis of reference sections of pertinent systematic reviews [8,9], 17 articles were finally included [8-24]. Eight studies were excluded because they didn’t meet the eligibility criteria. Sixteen out of the 17 articles included were case reports [8-10,12-24], and one was a case series [11], with a total of 19 patients. Of these 19 patients, 53% (10/19) were males with a mean age of 48 (range 19-73) years old. Among these patients, a history of abdominal surgery was reported only in 8 patients (42%): three had surgery for colorectal cancer, one for jejunal carcinoid, one for splenectomy, one for cesarean delivery, one for endometriosis and appendicectomy, one for perforated ulcer. As shown in Table 1 the clinical question for colonoscopy differed between the studies analyzed, being abdominal pain, the most frequent indication (21%) followed by chronic diarrhea (16%) and polyp resection (16%). Other indications were colon cancer follow-up, rectal bleeding, screening, iron deficiency anemia, family history of colon polyps, family history of colon cancer, personal history of colon polyps, and assessment of colostomy closure. In all cases, colonoscopy was conducted to the cecum. Concerning procedures eventually performed during the endoscopic procedures, polypectomies and biopsies were performed in 8 and 5 patients respectively, whilst endoscopic submucosal dissection was performed in one patient, and one patient with a 4 cm polyp of terminal ileum was referred to surgery.

 

Figure 1: Flowchart of included studies.Table 1: the main characteristics and results of included studies in the systematic review.